Fetal Monitoring - WordPress.com

Fetal Monitoring - WordPress.com

ATI Review Lucy Van Otterloo, RN, MSN Which hormone is directly responsible for ovulation? A. Estrogen B. Progesterone C. Luteinizing hormone (LH) D. Follicle-stimulating hormone (FSH)

C. LH initiates the ovulation process in the ovary and works with FSH to stimulate the growing follicle. Once the follicle ruptures, LH continues to stimulate the ruptured follicle to produce estrogen, which stimulates the surge of LH from the anterior pituitary, beginning the process again.

The physician prescribes the fertility drugs menotropins (Pergonal) and chorionic gonadotropin (Pregnyl). The nurse should instruct the client that the combined action of these drugs is to: A. Stimulate and promote ovulation B. Prepare the uterus for implantation C. Prevent endometriosis in the fallopian tubes

D. Facilitate patency of the fallopian tubes A. Mentropins (Pergonal) stimulates maturation of the ovum and chorionic gonadotropin (Pregnyl) stimulates ovulation, thus increasing the womans chance for fertilization and implantation.

The time of ovulation can be determined by taking the basal temperature. During ovulation the basal temperature: A. B. C. D. Drops markedly Drops slightly and then rises Rises suddenly and then falls Rises markedly and remains high

B. As ovulation approaches, there may be a drop in the basal temperature because of an increased production of estrogen; when ovulation occurs, there will be a rise in the basal temperature because of an increased production of progesterone.

A couple who recently emigrated from Israel are concerned about a genetic disease that is prevalent among Jewish people and speak to the clinic nurse. The nurse recommends that they go for a genetic blood test to determine the possibility of any of their children being born with: A. B. C. D.

PKU Cystic fibrosis Cooleys anemia Tay-Sachs disease D. This is a genetic disorder transmitted as an autosomal recessive trait that occurs primarily among Ashkenazi Jews.

After the first 3 months of pregnancy, the chief source of estrogen and progesterone is the: A. B. C. D. Placenta Adrenal cortex Corpus luteum Anterior hypophysis

A. When placental formation is complete, around the 12th week of pregnancy, it produces progesterone and estrogen During prenatal development, fetal weight gain is greatest in the: A.

B. C. D. First trimester Third trimester Second trimester Implantation period B. This is the period in which the

fetus stores deposits of fat. In dealing with a couple identified as having an infertility problem, the nurse knows that: A. Infertility is usually psychologic in origin B. Infertility and sterility are essentially the same problem C. The couple have been unable to have a child after trying for a year D. One partner has a problem that

makes that person unable to have children C. Infertility is the inability of a couple to conceive after at least 1 year of adequate exposure to the possibility of pregnancy. A test commonly used to determine the

number, motility and activity of sperm is the: A. B. C. D. Rubin test Friedman test Postcoital test Papanicolaou test

C. This test determines the number and condition of sperm aspirated from the cervix within 2 hours after intercourse Which of the following is considered a positive sign of pregnancy? A. B.

C. D. A missed menstrual period Abdominal enlargement Fetal movement felt by provider Positive pregnancy test C. Positive pregnancy signs include fetal heart sounds, fetal movement

palpated by an experienced examiner, and visualization of fetus by ultrasound. All other signs are presumptive or probable and may indicate other conditions. The nurse is aware that an adaptation of pregnancy is an increased blood supply to the pelvic region that results in a purplish discoloration of the vaginal mucosa, which is known as: A.

B. C. D. Ladins sign Hegars sign Goodells sign Chadwicks sign D. A purplish color results from

increased vascularity and blood vessel engorgement of the vagina. Ladins sign is increased vascularity of the cervix. Hegars sign is softening of the lower uterine segment. Goodells sign is softening of the cervix. The uterus rises out of the pelvis and becomes an abdominal organ at about the A.

B. C. D. 10th week of pregnancy 8th week of pregnancy 12th week of pregnancy 18th week of pregnancy C. By this time the fetus and

placenta have grown, expanding the size of the uterus. The extended uterus expands into the abdominal cavity. The nurse plans teaching for a client scheduled for amniocentesis. It is MOST important for the nurse to include which of the following statements?

A. The test assesses gestational age using the biparietal circumference B. The test determines the gender of the baby C. The test is used to detect possible birth defects D. The test should not be completed if you have a hx. of miscarriages C.

Completed to determine genetic disorders or neural tube defects; takes 2-4 weeks to obtain results. BPD is determined by sonogram. Gender can be done but that is not the primary reason. Previous miscarriage is not a contraindication. Procedure may cause preterm labor. A pregnant client works at a computer entering data. This would necessarily have

implications for her plan of care during pregnancy. The nurse should recommend that the client: A. Try to walk about every few hours during the workday B. Ask for time in the morning and afternoon to elevate her legs

C. Tell her employer she cannot work beyond the second trimester D. Ask for time in the morning and afternoon to obtain nourishment A. Maintaining the sitting position for prolonged periods may constrict the vessels of the legs, particularly in the popliteal spaces, as well as diminish venous return. Walking contracts the

muscles of the legs, which apply gentle pressure to the veins in the legs, thus promoting venus return. A client is concerned about gaining weight during pregnancy. The nurse explains that the largest part of weight gain during pregnancy is because of: A. B. C. D.

The fetus Fluid retention Metabolic alterations Increased blood volume A. The average weight gain during pregnancy is 25 to 35 lbs; of this, the fetus accounts for 7 to 8 lbs. or approximately 30% of weight gain

Amniotic fluid increases during pregnancy. The nurse is aware that one of the major functions of amniotic fluid and its increase during pregnancy is to: A. Provide antibodies to the fetus B. Increase nutrients to the fetus C. Maintain fetal temperature stability D. Ease passage during delivery

C. The major functions of amniotic fluid are to provide the fetus with a protective cushion, keep the fetus at an even temperature, and aid in dilation of the cervix. Physiologic anemia during pregnancy is a result of: A.

Decreased dietary intake of iron B. Increased plasma volume of the mother C. Decreased erythropoiesis after the first trimester D. Increased detoxification demands on the mothers liver B. There is a 30% to 50% increase in

maternal plasma volume at the end of the first trimester, leading to a decrease in the concentration of hemoglobin and erythrocytes. In the 12th week of gestation, a client completely expels the products of conception. Because the client is Rhnegative, the nurse must: A. Administer RhoGAM within 72 hours B. Make certain she receives RhoGAM

on her first clinic visit C. Not give RhoGAM since it is not the birth of a stillborn D. Make certain the client does not receive RhoGAM since the gestation only lasted 12 weeks A. It is given within 72 hours postpartum if the client has not been sensitized previously.

A client at 12 weeks gestation comes to the prenatal clinic complaining of severe nausea and vomiting. The nurse suspects that this client has hyperemesis gravidarum and knows that this is frequently associated with: A. Excessive amniotic fluid B. A GI history of cholecystitis C. High levels of chorionic gonadotropin

D. Slowed secretion of free hydrochloric acid B. High levels of chorionic gonadotropin frequently are associated with severe vomiting of pregnancy; especially in the presence of hydatidiform mole (gestational trophoblastic disease) and often in twin pregnancy

The care of a client with placenta previa includes: A. Vital signs at least once per shift B. A tap-water enema before delivery C. Observation and recording of the bleeding D. Limited ambulation until the bleeding stops

C. Continued bleeding can put the fetus in jeopardy. The client should be restricted to complete bed rest until bleeding stops. Vital signs should be recorded every 4 hours until bleeding stops. A pregnant client develops thrombophlebitis of the left leg and is admitted to the hospital

for bedrest and anticoagulant therapy. The anticoagulant the nurse should expect to administer is: A. B. C. D. Heparin Dicumerol Diphenadione (Dipaxin) Wafarin (Coumadin)

A. Heparin is used because its molecular size is too large to pass the placental barrier. The other three drugs can pass the placental barrier and cause hemorrhage in the fetus. A client who is 6 months pregnant comes to the prenatal clinic complaining of painful

urination, flank tenderness, and hematuria. A diagnosis of pyelonephritis is made. An important nursing intervention for the client at this time is: A. Limiting fluid intake B. Examining the urine for protein C. Observing for signs of preterm labor D. Maintaining her on a 2-gram sodium diet

C. Pyelonephritis often causes preterm labor, leading to increased neonatal morbidity and mortality. When taking the health history, the nurse correctly identifies that a client is at risk for developing a hypertensive disorder of pregnancy when it is determined that the client:

A. Is 31 years old B. Is an obese primigravida C. Has had six previous pregnancies D. Has been on oral contraceptives within 3 months of pregnancy B. First pregnancy and obesity are both documented risk factors. The

risk age for a hypertensive disorder of pregnancy is under 20 and over 35 years of age. Multigravidity is not a risk factor and neither is oral contraceptive use. A pregnant client asks the clinic nurse how smoking will affect her baby. The nurses response reflects the knowledge that: A. The placenta is permeable to

specific substances B. Smoking relieves tension and the fetus responds accordingly C. Vasoconstriction will affect both fetal and maternal blood vessels D. Fetal and maternal circulation are separated by the placental barrier C. Cigarette smoking or continued exposure to secondary smoke causes

both maternal and fetal vasoconstriction, resulting in fetal growth restriction and increased fetal and infant mortality The nurse auscultates the abdomen of a 38 weeks gestation to determine fetal heart rate. If the fetal heartbeat is located in the right lower quadrant, which of the following is MOST likely the presenting part? A. B.

C. D. Shoulder Head Feet Buttocks B. With vertex presentation, ROA. Feet (footling) or buttocks (frank)

breech would hear FHT in upper quadrant. Shoulder is uncommon, only 1% of births. After doing Leopolds maneuvers on a laboring cient, the nurse determines that the fetus in in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed: A. Above the umbilicus in the midline

B. Above the umbilicus on the left side C. Below the umbilicus on the right side D. Below the umbilicus near the left groin C. Fetal heart tones are best auscultated through the fetal back; because the position is ROP, the back would be below the umbilicus and on the right side

When caring for a woman with a positive contraction stress test, the nurse should be most concerned with observing her for signs and symptoms of: A. B. C. D. Preeclampsia Placenta previa

Imminent pretem delivery Uteroplacental insufficiency D. A positive CST indicates a compromised fetal heart rate during contractions, which is associated with uteroplacental insufficiency A laboring womans uterine contractions are being internally

monitored. When evaluating the monitor tracing, which of the following findings would be a source of concern and require further assessment? A. Frequency every 2.5 to 3 minutes B. Duration of 80-85 seconds C. Intensity of 85-90 mmHg D. Resting pressure of 20-25 mmHg Correct

answer: D The resting pressure should be 15 mmHg or less The nurse caring for women in labor should be aware of signs characterizing reassuring FHR patterns. A reassuring sign would be:

A. Moderate baseline variability B. Average baseline FHR of 90-110 beats/min C. Transient episodic deceleration with movement D. Late decelerations approx. every 3-4 contractions Correct

answer: A The baseline rate should be 110-160 beats/min; accelerations should occur with featl movement; no late deceleration pattern of any magnitude is reassuring A laboring womans temperature is elevated as a result of an upper respiratory infection. The FHR pattern that reflects maternal fever would be:

A. Diminished variability B. Variable decelerations C. Tachycardia D. Early decelerations Correct

answer: C The FHR increases as the maternal core body temperature elevates, so tachycardia would be the pattern exhibited. It is often a clue of intrauterine infection because maternal fever is often the first sign. A nulliparous woman is in the active phase of labor and her cervix has progressed to 6 cm dilation. The

nurse caring for this woman evaluates the external monitor tracing and notes the following: decrease in FHR shortly after onset of several contractions, returning to baseline rate by the end of the contractions; shape is uniform. Based on these finding, the nurse should:

A. Change the womans position to her left side B. Document the finding on the womans chart C. Notify the physician D. Perform a vaginal examination to check for cord prolapse Correct answer: B The pattern described is an early deceleration pattern, which is

considered to be benign, reassuring, and requiring no action other than documentation of the finding. The nurse has auscultated a fetal heart rate of 80. What should be the nurses initial action? A. Position the client on her left side B. Administer oxygen at 5L/minute

C. Notify the physician or nurse-midwife D. Check the maternal pulse Correct answer: D Key word is auscultated the nurse may be hearing the maternal blood flow through the uterus and not the fetal heart rate.

At about 5 cm. dilation, a laboring client receives medication for pain. The nurse is aware that one of the medications given to women in labor that could cause respiratory depression of the newborn is: A. B. C. D. Scopolamine Promazine

Meperidine (Demerol) Promethazine (Phergan) C. Respiratory depression occurs with the use of meperidine and produces significant depression of the infant at birth if circulating levels are high at time of birth. The nurse in the birthing suite has just

admitted the following four clients. Which one of these clients should the nurse prepare for cesarean section? A. Multipara with a shoulder presentation B. Multipara with a documented station of floating C. Primigravida with a fetus presenting in occiput posterior D. Primigravida with twin gestation

with lower most twin in vertex position. A. Multipara with a shoulder presentation is indicative of a transverse lie; this indicates the need for a cesarean section. A client is admitted to the hospital in active labor. After an amniotomy the nurse would expect:

A. Increased fetal heart rate B. Diminished bloody show C. Less discomfort with contractions D. Progressive dilation and effacement D. Artificial rupture of membranes

(AROM) allows for more effective pressure of the fetal head on the cervix, enhancing dilation and effacement. During a clients labor, the fetus head is at station +1. This indicates that the presenting part is: A. B. C. D.

On the perineum High in the false pelvis Slightly below the ischial spines Slightly above the ischial spines C. The term station is used to indicate the location of the presenting part. The level of the tip of the ischial spines is considered to

be zero. The position of the bony prominence of the fetal head is described in centimeters minus (above the spines) or plus (below the spines) A client is admitted to the birthing suite in early active labor. The priority nursing intervention on admission of this client would be: A.

Auscultating the fetal heart B. Taking an obstetric history C. Asking the client when she ate last D. Ascertaining whether the membranes are ruptured A. Determining fetal well-being supersedes all other measures. If

the fetal heart rate is absent or persistently decelerating, immediate intervention is required. A client is admitted to the labor unit in the latent phase of the first stage of labor, with contractions lasting 20 seconds. In assessing the clients emotional status, the nurse would anticipate that the client will be: A. B. C.

D. Serious Happy Irritable panicky B. In the first stage of labor when complications are absent and contractions are weak, the client

experiences minimal discomfort. She is usually excited, happy, and eager. As labor progresses she becomes more serious and is more likely to become irritable, tired, and sometimes panicky. A multigravida client is admitted in active labor. She is yelling, Hurry! Hurry! The baby is coming! What priority action by the nurse is indicated? A.

B. C. D. Check the fetal heart tones Time the contraction interval Determine the presenting part Do a vaginal examination D. A vaginal examination should be

performed to determine the presenting part so preparation can be made for delivery. A nurse is assessing a client in labor and finds that her contractions are lasting 60 seconds every 4 minutes and that her cervix is 6 cm dilated. The nurse would document that the client is in what stage of labor? A. B. C.

D. Active phase Early phase Latent phase Transitional phase A. During active labor the contractions begin to last longer and are occurring more frequently.

Cervical dilation occurs rapidly during active labor and usually progresses from 4 to 7 cm. The nurse teaches a pregnant woman to avoid lying on her back during labor. The nurse has based this statement on the knowledge that the supine position can: A. Unduly prolong labor B. Cause decreased placental perfusion

C. Lead to transient episodes of hypertension D. Interfere with free movement of the coccyx B. This is because of impedance of venous return by the gravid uterus, which causes hypotension and decreased systemic perfusion

The husband of a client who is in the transitional phase of labor becomes very tense and nervous during this period and asks the nurse, Do you think it is best for me to leave, since I dont seem to do my wife much good? The most appropriate response by the nurse would be:

A. This is the time your wife needs you. Dont run out on her now. B. This is hard for you. Let me try to help you coach her during this difficult phase. C. I know this is hard for you. Why dont you go have a cup of coffee and relax and come back later if you feel like. D. If you feel that way, youd best go out and sit in the waiting room for a while because you may transmit your anxiety to your wife. B.

Both the father and the mother need additional support during the transitional stage of labor A client who was admitted in active labor has only progressed from 2 cm to 3 cm in 8 hours. She is diagnosed as having hypotonic dystocia and is given oxytocin to augment her contractions. The most important aspect of nursing at this time is: A.

Monitoring the FHR B. Checking the perineum for bulging C. Preparing for an emergency cesarean birth D. Timing and recording length of contractions D. The oxytocic effect of Pitocin increases the intensity, duration and

frequency of contractions; prolonged contractions will jeopardize the safety of the fetus and necessitate discontinuing the drug An expectant couple asks the nurse about the cause of low back pain in labor. The nurse replies that this pain occurs most when the position of the fetus is: A. B. C.

D. Breech Transverse Occiput anterior Occiput posterior D. A persistent occiput posterior position causes intense back pain because of fetal compression of the

sacral nerves. A client is 39 weeks pregnant and in labor. Her physician has informed her that she will have to have a cesarean birth because she has: A. B. C. D. Gonorrhea

Chlamydia Chronic hepatitis Active genital herpes D. Once the membranes have ruptured, the active herpes infection ascends and can infect the fetus; since herpes does not cross the placenta, a cesarean birth can decrease transfer of the virus to the

fetus The nurse working in a triage clinic should return which of the following clients telephone messages first? A. 37 weeks of gestation with SOB B. 10 weeks of gestation with breast tenderness C. 35 weeks of gestation with feet that well at the end of the day

D. 12 weeks of gestation with darkening blotches of skin over her cheekbones A. The first call should be made to the woman who is complaining of dyspnea. A woman who is in her 37th week can have dyspnea from the term gravid uterus pushing up on her diaphragm, but she may also be

experiencing a respiratory emergency such as pulmonary embolus. When a client is admitted to the labor suite with a BP of 130/90, 2+ proteinuria, and edema of the hands and face, the nurse should ask the client about the presence of:

A. Constipation, edema, visual problems, headache B. Visual disturbances, headaches, constipation, bleeding C. Leakage of fluid, bleeding, edema, pain in the abdomen D. Headache, visual disturbances, edema, pain in the abdomen D.

To ascertain the severity of preeclampsia, these are the signs that must be assessed. The nurse is caring for a woman at 37 weeks gestation. The nurse would be MOST concerned by which of the following findings? A. The patient c/o right quadrant

pain B. BP 150/95 C. 4+ proteinuria D. 3+ pitting edema A. Indicates impaired liver function, sign of impending eclampsia. B/P greater than 160/110 considered severe preeclampsia, 4+ proteinuria indicates severe preeclampsia, and

3+ pitting edema is indicative of mild preeclampsia A client is on magnesium sulfate therapy for severe preeclampsia. The nurse must be alert for the first sign of an excessive blood magnesium level, which is: A. Disturbance in sensorium B. Increase in respiratory rate C. Development of cardiac

dysrhythmia D. Disappearance of the knee-jerk reflex D. Magnesium sulfate has a CNS depressant effect therefore, toxic levels will be reflected in decreased respiration and the absence of the knee-jerk reflex. Cardiac dysrhythmia occurs with increased

potassium not magnesium sulfate. A pregnant client is receiving magnesium sulfate for eclampsia. Which medication should the nurse have available as an antidote for possible toxicity? A. B. C. D. Vitamin K

Calcium gluconate Naloxone (Narcan) Diazepam (Valium) B. Calcium gluconate is the antagonist to magnesium sulfate that would be ordered if toxicity occurs. A 26 year-old woman is brought to the emergency room complaining of severe left lower quadrant

pain. She tells the nurse that she performed a home pregnancy test and believes she is 8 weeks pregnant. On admission the patients vital signs are pulse 90, BP 110/70, respirations 20. A half-hour later her vital signs are pulse 120, BP 86/50, respirations 26. The nurse interprets the change in the patients vital signs to mean that: A. The patients pain may have increased B. The patient may be bleeding internally C. The patient may be frightened

D. The patient may have an infection B. Decreased BP equals decreased intravascular volume; shock. BP increases with pain and fear. Infection usually wont change BP unless in septic shock. The nurse is caring for clients in the labor and delivery unit. The nurse notes that a

clients membranes have ruptured and the amniotic fluid is meconium-stained. The nurse determines that there is no prolapsed cord. Which of the following actions should the nurse take NEXT? A. Contact the health care provider B. Assess fetal heart tones C. Start an intravenous line D. Obtain the clients pulse and blood pressure

B. Meconium-stained amniotic fluid may be an ominous sign; assess for nonreassuring fetal heart tone patterns-fetal bradycardia, irregular FHR, late, severe variables and prolonged deceleration patterns; if fetal distress, turn client to left side, give O2 and start IV.

Abruptio placentae is most likely to occur in a woman with: A. B. C. D. Cardiac disease Hyperthyroidism Gestational hypertension Cephalopelvic disproportion

C. Hypertension during pregnancy leads to vasospasms; this in turn causes the placenta to tear away from the uterine wall. The nurse cares for an 18 year-old woman in the labor unit. During the transitional phase of labor the umbilical cord becomes prolapsed. The nurse should place the patient in which of the following positions?

A. B. C. D. Lithotomy Side-lying Semi-fowlers Trendelenberg D.

Gravity relieves pressure on cord from fetal head. Or put finder against presenting part and shift weight off cord. Lithotomy used for examination of vagina or rectum. Side-lying removes weight from vena cava, does not help with prolapsed cord. Semi-fowlers aggravates prolapsed cord. Despite medication, a clients preterm labor continues, her cervix dilates, and birth

appears inevitable. The nurse understands the infants chance of extrauterine survival may improve if the physician orders: A. Ampicillin by piggyback B. Dexamethasone by infusion C. An immediate cesarean delivery D. An intrauterine exchange transfusion B.

Steroids are given for a short period before delivery; by some obscure mechanism, they help to mature the fetus lungs A client experiences a normal newborn delivery. After the placenta is delivered, the physician orders a medication to be added to the IV solution. Which medication is the nurse most likely administering at this time? A.

B. C. D. Penicillin Atropine Oxytocin AquaMEPHYTON C. Oxytocin (Pitocin) stimulates

uterine contractions. When oxytocin is given after delivery of the placenta, the contractions stimulated by the drug help control bleeding. During the postpartum period after a cesarean birth, the nurse examines the client and identifies the presence of lochia serosa and feels the fundus four fingerbreadths below the umbilicus. This indicates that the time elapsed is: A.

B. C. D. 1 to 3 days postpartum 4 to 5 days postpartum 6 to 7 days postpartum 8 to 9 days postpartum B. The fundus descends one

fingerbreadth per day from the first postpartum day; lochia serosa begins to flow on the fifth day. A client after a vaginal delivery is at risk for postpartum hemorrhage. Nursing education to prevent postpartum hemorrhage is based on the knowledge that priority explanation for the cause is: A. B. C.

D. Laceration of the perineal area Uterine rupture High parity Uterine atony D. About 75% of all hemorrhages are due to uterine atony, which is the lack of uterine tone. Laceration of

the perineal area, uterine rupture and high parity are other causes of hemorrhage, but they are not as likely. The nurse working on the postpartum unit should encourage clients to ambulate early to: A. Promote respirations

B. Increase the tone of the bladder C. Maintain tone of abdominal muscles D. Increase peripheral vasomotor activity D. There is extensive activation of the blood clotting factor after delivery; this, together with immobility, trauma or sepsis,

encourages thromboembolization, which can be limited through activity. Since having a baby by cesarean section, a client has walked to the nursery numerous times to see her baby each day. Two days postpartum, the client complains of pain in the right leg. The nurses initial response should be to: A.

Apply hot soaks B. Massage the affected limb C. Encourage ambulation and exercise D. Maintain bed rest and notify the physician D. Although thrombophlebitis is suspected, before a definitive diagnosis the client should be

confined to bed so that further complications may be avoided. A nurse assesses a client who delivered 1 hour ago. The fundus is firm and two fingerbreadths below the umbilicus, and the lochia is bright red. The client complains of having chills. What would the nurse recognize based on this assessment? A. An inverted uterus

B. Acute hemorrhage C. A normal postpartum response D. The early stage of hypovolemic shock C. After delivery, the uterus continues to contract and reduce in size. The client should be covered and kept warm because chills are a normal process immediately after

delivery. Red, bloody lochia is normal at this time as well. When is a client most likely to experience postpartum depression? A. B. C. D. Within the first 48 hours Within the first 72 hours

By the fourth or fifth day During the second week C. Elevated hormone levels begin to fall by the fourth or fifth day after delivery. This shift in hormones causes the depressed mood. Depending on their coping ability, some women may experience more severe depression than others.

When checking a clients fundus on the second postpartum day, the nurse observes that the fundus is above the umbilicus and displaced to the right. The nurse evaluates that the client probably has: A. B. C. D. A slow rate of involution

A full, overdistended bladder Retained placental fragments Overstretched uterine ligaments B. A distended bladder will displace the fundus upward and laterally A postpartum client experiences a temperature spike of 101 F (38.3 C) 12 hours after delivery. What would the nurse

suspect? A. B. C. D. Infection Hemorrhage Dehydration A normal response C.

Fever within the first 24 hours postpartum indicates dehydration. After 24 hours, however, it is indicative of a puerperal infection. During early postpartum, when assessing a clients episiotomy, the nurse identifies edema with severe ecchymosis. Also, the client is complaining of severe perineal and rectal pressure. The fundus is firm, and there is no lochia. The clients vital signs are

T 99 F, P 108, R 20, BP 105/60. This assessment most likely indicates a: A. B. C. D. Urinary infection Uterine infection Vaginal hematoma Postpartum hemorrhage

C. These are classic signs and symptoms of a vaginal hematoma The nurse identifies that a woman needs further teaching about breastfeeding her newborn when she: A. Leans forward and puts her breast into the infants mouth

B. Holds the infant level with her breast and in a side-lying position C. Touches her nipple to the infants lips when beginning the feeding D. Puts her finger in the infants mouth to break the suction when switching breasts A. When the breast is pushed into the infants mouth a typical response

is for the mouth to close too soon, resulting in inadequate latching-on The nurse should plan to teach a recently delivered client who is formula-feeding her infant to minimize breast discomfort by: A. Gently applying cocoa butter B. Manually expressing colostrum C. Applying covered ice packs to her breasts

D. Placing warm, wet washcloths on her nipples C. Covered ice packs promote comfort by decreasing vasocongestion A client with mastitis is concerned about breastfeeding her newborn infant. Which recommendation should the nurse provide

to the client? A. Stop breastfeeding until after completing antibiotics B. Supplement feeding with forumla until the infection resolves C. Continue to breastfeed because mastitis will not infect the infant

D. Do not use analgesics because they may be passed to the newborn through breast milk C. The client with mastitis should be encouraged to continue breastfeeding while taking antibiotics for the infection. No supplemental feedings is necessary because breastfeeding does not need to be altered and actually encourage resolution of the

infection. Analgesics are safe and should be used as needed. A nurse makes all the following observations of a mother who is interacting with her newborn 8 hours after delivery. Which observation would alert the nurse to a potential problem with the maternal-infant attachment?

A. The mother speaks to the newborn during crying spells. B. The mother undresses the newborn during a diaper change. C. The mother takes the newborn with her to the baby care classes. D. The mother consistently engages eye contact with the father as she feeds the newborn.

D. Maternal-infant bonding is evidenced by the mother-infant interactions. This mother seems focused primarily on her husband, which may indicate a problem with bonding. During which phase of maternal psychological adaptation is it best for a nurse to teach a postpartum client

about caring for a newborn infant? A. B. C. D. Taking-in Letting-go Taking-hold Letting-down C.

Beginning after the completion of the taking-in phase, the taking-hold phase lasts about 7 days. During this phase, the client is concerned with her need to resume control of all facets of her life in a competent manner. At this time, she is ready to learn self-care and infant-care skills. A 28 year-old woman has just delivered her first child, a boy weighing 6 lbs.

and 2 oz. The Apgar scores at one and five minutes are 8 and 9. The nurse understands that: A. An isolette should be ready in the nursery for close observation of this infant B. The newborn is making an optimal transition to extrauterine life

C. The parents will need emotional support to deal with a less than perfect child D. High Apgar scores correlate well with future emotional and intellectual development B.

Good Apgar. Nursery care is not needed and there is no relationship between Apgar and future emotional/ intellectual development. An infant born in the 36th week of gestation weighs 4 lbs 9 oz (2062 gms) and has an Apgar of 7/9. On admission to the nursery, it would be unnecessary for the nurse to: A. B.

C. D. Record vital signs Administer oxygen Support body temperature Evaluate the newborns status B. The babys Apgar score (7/9) does not indicate a need for oxygen.

At 10 hours of age an infant has a large amount of mucus and becomes slightly cyanotic. The nurse should first: A. B. C. D. Insert a Levin tube Give the infant oxygen Suction the mucus as needed

Note the incident on the chart C. To maintain a patent airway and promote respiration and gaseous exchange, mucus must be removed. When observing a newborn for signs of pathologic jaundice, the nurse should be alert for: A.

Muscular irritability at birth B. Neurologic signs during the first 24 hours C. The appearance of jaundice during the first 24 hours D. Jaundice developing between the second and fourth day of life C. Development of jaundice in the

first 24 hours indicates hemolytic disease of the newborn requiring immediate medical investigation. Jaundice occurring between 48 and 72 hours after birth is a consequence of the normal physiologic breakdown of fetal RBCs and immaturity of the liver. Which of the following observations of an 8 lb 4 oz newborn boy, if made by the nurse, would require an intervention?

A. The infants respirations are 36, shallow and irregular in rate, rhythm, and depth B. Rapid pulsations are visible in the fifth intercostal space, left midclavicular line C. The infants axillary temperature is 96.2 F (35.6 C) D. There is asynchronous spontaneous movement of the infants extremities

C. Subnormal temperature indicates prematurity, infection, low environment temperature, inadequate clothing, and dehydration. A newborn is diagnosed as having Erbs Palsy. The nurse is aware that this problem is caused by:

A. A disease acquired in utero B. An X-linked inheritance pattern C. A tumor arising from muscle tissue D. An injury to the brachial plexus during birth D. The brachial plexus is injured by

excessive pressure during a difficult delivery requiring the use of forceps or during a breech delivery; it is considered a birth injury and not related to genetic factors or disease. Asymmetric Moro reflexes are frequently associated with: A. Downs syndrome B. Cranial nerve damage

C. Cerebral or cerebellar injuries D. Brachial plexus, clavicle or humerus injuries D. Injury to the brachial plexus, clavicle, or humerus prevents abduction and adduction movements of an upper extremity. A newborn has asymmetric gluteal

folds. The nurse suspects: A. CNS damage B. Dysplasia of hip C. An inguinal hernia D. Peripheral nervous system damage B. Asymmetric gluteal and leg folds

indicates hip dysplasia. Gluteal folds are elevated on the affected side. A nurse is assessing a newborn and recognizes which of the following as a sign of postmaturity? A. B. C. D. Smooth, supple skin

Long, brittle fingernails Well-developed eyebrows Creases in the soles of the feet B. The fingernails begin to form around 12 weeks gestation. By 39 to 40 weeks, the nails have covered the nailbeds. After 40 weeks, the nails begin to extend and have a long appearance.

Which finding would be manifested in an infant with a myelomeningocele? A. Clubbed feet and muscle spasms in the legs and arms. B. Obstruction of bowel and impaired bladder function C. Spastic movement of upper and lower extremities D. Impaired bowel and bladder

function and paralysis of the legs. D. The nerves of the cauda equina are involved with a myelomeningocele, which results in lower extremity paralysis. Innervation to the anal sphincter and the bladder is decreased, causing incontinence. Bowel function may be affected, but there is no obstruction and the upper

extremities are not affected. A new mother expresses concern over strabismus in her infant. What would the nurse explain to the mother regarding this condition? A. B. C. D. It is a normal finding in newborns

This may be a permanent defect It will require corrective surgery It will result in imparied vision A. Muscle control of the eyes in the newborn is undeveloped, resulting in temporary strabismus, or a crosseyed appearance. This is considered normal in the newborn. Which observation in a 24 hour-old newborn

should be reported to the physician immediately? A. Blotchy, mottled skin B. Positive Babinski reflex C. Tremors and spasms of all extremities D. High-pitched crying and arching of the back D.

A high-pitched cry and arching of the back are cardinal signs of a neurological problem.

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